GI Endoscopy · 7 min read
Boerhaave: Mackler Triad Is Incomplete, CT First, Then Drain and Cover or Operate
Transmural distal-left rupture after vomiting is a mediastinal emergency. A mucosal Mallory-Weiss tear bleeds. It does not soil the chest.
Clinical Bottom Line
| Question | Practical answer |
|---|---|
| What is Boerhaave? | Spontaneous transmural rupture, usually distal left posterolateral esophagus, after vomiting. Mediastinitis and pleural contamination, not hematemesis as the main story. |
| Mackler triad | Vomiting, lower chest pain, subcutaneous emphysema. Incomplete in many series. Do not require all three. |
| First test | CT chest and abdomen with water-soluble oral contrast. Swallow study if CT is equivocal and suspicion stays high. |
| Endoscopy | Not the screening test. Use it, with low insufflation, when you already plan endoscopic coverage or to define a tear the CT already found. |
| Treatment | NPO, IV antibiotics covering oral flora, acid suppression, drain collections. Covered SEMS or vacuum therapy for selected contained leaks. Surgery if uncontained, delayed, or unstable (WSES 2019, PMID 31164915). |
How is this not Mallory-Weiss?
Mallory-Weiss is a mucosal laceration, usually at the GEJ, that presents with bleeding after retching. Boerhaave is a blowout through muscle. The patient looks septic or has a hydropneumothorax, not a stable GI bleed. There is no Mallory-Weiss permalink in this set. Keep the distinction on this page instead of inventing a second URL.
The weak point is the left posterolateral distal third, a few centimeters above the GEJ, where surrounding support is thin. That is why left pleural fluid and mediastinal air are the CT pattern you look for.
What does WSES actually want?
Chirica 2019 (PMID 31164915) is the World Society of Emergency Surgery esophageal-emergencies guideline. Time to source control is the variable that moves mortality. NPO, resuscitation, broad antibiotics, and drainage of pleural or mediastinal collections are not optional add-ons to a stent.
Iatrogenic perforations recognized during the index endoscopy can often be closed immediately with clips or a covered stent. Spontaneous Boerhaave is not that case. Endoscopic coverage is reasonable for selected contained leaks when a multidisciplinary team can drain the chest. Uncontained soilage, delayed presentation, and hemodynamic instability still belong to surgery.
Covered stents, when used, stay long enough to seal, commonly in the 2-4 week range in the WSES discussion, then come out. Endoscopic vacuum therapy is an option in centers that already run it. Neither device replaces a drain.
Selected references
Last reviewed September 20, 2026. Written for clinicians who heard vomiting then chest pain and now have to choose CT, a covered stent, drainage, or a thoracotomy.
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